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LONGS DRUGS OF LEXINGTON
RWII29204 Palmetto AIDS Life Support Services, Inc.
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Covered Entity Details
Entity Name
Palmetto AIDS Life Support Services, Inc.
Subdivision Name
Type
Ryan White Part B
340B ID
RWII29204
Entity Address
2638 Two Notch Road
Suite 108
Columbia, SC 29204-1454
Grant Number
X07HA00038
Participating Start Date
10/1/2016
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
LONGS DRUGS OF LEXINGTON
Pharmacy Address
D/B/A AVITA PHARMACY 1051
1216 W MAIN ST
STE D
LEXINGTON, SC 29072-2453
Pharmacy Comments
Contract Details
Approval Date
10/18/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Carmen H. Julious, CEO
(803) 779-7257
Contract Pharmacy Representative
Avita Pharmacy
JERRY PURCELL, CEO/PRESIDENT
(504) 905-4587
Signed By Date
10/18/2016
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